11 Spinal cord Disease Focal T2 Hyperintense lesions in cord WM >3mm but <two vertebral body heights Little or no swelling of the cord Occupy only part of cross section of the cord Best identified in cervical region More specific than brain lesions Long section of inflammation >3 vertebral heights Neuromyelitis Optica (NMO)

15 McDonald Criteria out of 4 of the following: A) One Gd enhancing or nine T2 hyperintense lesions if no enhancement B) At least one infratentorial lesion C) At least on juxtacortical lesion (involving U fibres) D) At least three periventricular lesions One spinal cord lesion can be substituted for one infratentorial lesion.

16 Revised criteria 2005 Revision incorporated precise criteria for use of spinal cord lesions in diagnosis: Cord lesions need to be focal to satisfy criteria One spinal cord lesion can be substituted for one infratentorial lesion. An enhancing spinal cord lesion can be used for an enhancing brain lesion Individual spinal cord T2 Hyperintense lesions can contribute to the 9 required overall

18 Clinically Isolated Syndrome Single episode - not able to diagnose MS Clinical Features Optic neuritis Sensorimotor High rate of conversion if brain WM lesions Up to 15% no clinical progressive despite MR WML +ve Advantage to early use of DMTs: Delay onset of second clinical episode Reduction in WM lesion accumulation

20 Relapsing Remitting MS Commonest MS course - 85%. 3:1 F:M Average age of onset 30 years Early disease - relapses and periods of remission Accumulate residual deficits from relapses Development of secondary progressive MS (SPMS) SPMS gait disorder requiring mobility assistance Natural history variable and unpredictable 60-70% conversion to SPMS, most in years 15% escape major attacks or SPMS Most important predictor of future disability - time taken to development of SPMS

22 First Generation DMTs Interferon beta and glatirmer acetate IM or sc administration Efficacy: Reduce relapse rate by one third Moderates development of new brain lesions over 1-3 years for CIS and RRMS Slow progress of disability only in first 2-3 years Efficacy reduced by neutralising antibodies Favourable safety profiles/minimal monitoring First line agents

28 MRI Prognosis No specific MRI markers at first presentation to indicate prognosis More rapid accumulation of T2 WM lesions in first 5 years - increased disability at 20 years Later in disease measures of cortical and deep grey matter atrophy become more important for prognosis

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